infertility patient history questionnaire - Center for Human ...

CENTER FOR HUMAN REPRODUCTION - CHR
21 East 69 th Street, New York, N.Y., 10021 Telephone: 212.994 4400; Fax: 212.994 4499
____________________________________________________________________________________________________________
PATIENT QUESTIONNAIRE
(Please complete entire questionnaire prior to initial consultation and e‐mail to __________________)
_______________________________________________________________________
Name Female ______________________ Occupation _________________
Name Male
______________________ Occupation _________________
Appointment with CHR physician: ☐ Norbert Gleicher, MD
☐ Vitaly Kushnir, MD
☐ David H. Barad, MD, MS
☐ Other: ______________________
On ___ /___ /___
My permanent residence is in: ___________________________________
I am able to conduct a consultation in English ☐
I require translations services for ________________ (language)
_______________________________________________________________________
I was referred to CHR by: ☐ former CHR patient
☐ my insurance
☐ my own research
☐ the Web
☐ a physician: _____________________ _____________
Name
Phone
_______________________________________________________________________
I/We tried to conceive since ___ / ___ / ___
I/We never tried to conceive ☐
I/We have been in fertility treatment since ___ / ___ / ___
I/We never have been in fertility treatment before ☐
I/We have never started an IVF cycle ☐
I/We have started ____ IVF cycles before. Amongst those ____ have
reached retrieval and ____ have reached embryo transfer.
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I/WE WAS/WERE PREVIOUSLY ADVISED THAT MY PRINCIPAL INFERTILITY
PROBLEM(s) IS/ARE:
___________________________________________
___________________________________________
___________________________________________
MY/OUR LAST TREATMENT RECOMMENDATION RECEIVED WAS:
____________________________________________
____________________________________________
________________________________________________________________________
FEMALE HISTORY
________________________________________________________________________
PLEASE IGNORE THIS SECTION IN ABSENCE OF A FEMALE PARTNER
Please tell us
your birth date: ___ / ___ / ____; and age: ____ years;
your height in feet and inches: ____ feet ____ inches; or in cms: ______;
your weight in pounds: ______; or in kg: _______;
How often have you been pregnant
Confirmed by ultrasound _____
but miscarried: _____
before fetal heart: _____
Delivered a baby: ____
after fetal heart: _____
Any complications ________________________________
but had only a chemical pregnancy: _____
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Some questions about your menstrual period:
How old were you at first menstrual period _____ years;
How many days are between one menstrual period and the next
days;
Is your menstrual pattern REGULAR ☐ or IRREGULAR ☐
When did your last menstrual period (LMP) start ___ / ___ / ___;
Date of your last PAP smear: ___ / ___ / ___; NORMAL ☐ ABNORMAL ☐ NEVER ☐
Date of your last mammogram: ___ / ___ / ___; NORMAL ☐ ABNORMAL ☐ NEVER ☐
Have parents, grandparents or siblings of yours been diagnosed with:
Breast cancer YES ☐ NO ☐; If YES, who ______________; What age ___ years
Ovarian cancer YES ☐ NO ☐; IF YES, who ______________; What age ___ years
Have you ever had any of the following If YES, please explain:
Surgeries: ____________________________________________________________
Psych treatments: _____________________________________________________
Hospitalizations: ______________________________________________________
Any medical treatments for longer than 2 weeks: ___________________________
Other medical conditions of significance: __________________________________
Skin rashes: __________________________________________________________
Unexplained medical symptoms: _________________________________________
Environmental or food allergies: _________________________________________
Medication allergies: ___________________________________________________
Any evidence of neurologic problems: _____________________________________
COMMENTS: _________________________________________________________
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Are you currently on any medications If YES, please list: ________________________
______________________________________________________________________
Are you up to date with your vaccinations schedule
Influenza ☐YES ☐NO ☐DON’T KNOW
Tetanus, diphtheria, whooping cough ☐YES ☐NO ☐DON’T KNOW
Measles, Mumps, Rubella (MMR) ☐YES ☐NO ☐DON’T KNOW
Pneumococcus ☐YES ☐NO ☐DON’T KNOW
Hepatitis A ☐YES ☐NO ☐DON’T KNOW
Hepatitis B ☐YES ☐NO ☐DON’T KNOW
Meningococcus ☐YES ☐NO ☐DON’T KNOW
Are there medical or genetic problems in your family If YES, please explain:
Your father: ___________________________________________________________
Your mother: __________________________________________________________
Your siblings: __________________________________________________________
Others: _______________________________________________________________
Where is your family from in the world
Your father’s family: ________________________________________________
Your mother’s family: _______________________________________________
Do you consider yourself: ☐AFRICAN ☐ASIAN ☐CAUCASIAN ☐ Other: __________
Is your ethnicity: ☐American Indian ☐ Arab ☐Black ☐ Chinese ☐Hispanic
☐Indian (Asian) ☐Indonesian ☐Japanese ☐Jewish‐Ashkenazi
☐Jewish Sephardic ☐Pakistani ☐Philippine ☐White
☐Other: __________________________________________________
Tell us whether you
Smoke ☐YES ☐NO ☐QUIT (when ________) If YES, how many ____
Drink more than socially ☐YES ☐NO
Use illegal and/or prescription drugs ☐YES ☐NO
are ☐single ☐have a boyfriend ☐are engaged ☐common law ☐married
☐in same‐sex relationship
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_______________________________________________________________________
EXTRA COMMENTS:
_______________________________________________________________________
_______________________________________________________________________
MALE HISTORY
_______________________________________________________________________
PLEASE IGNORE THIS SECTION IN ABSENCE OF A MALE PARTNER
Please tell us
your birth date: ___ / ___ / ____; and age: ____ years;
your height in feet and inches: ____ feet ____ inches; or in cms: ______;
your weight in pounds: ______; or in kg: _______;
Are you currently on any medications If YES, please list: ________________________
______________________________________________________________________
Are you up to date with your vaccinations schedule
Influenza ☐YES ☐NO ☐DON’T KNOW
Tetanus, diphtheria, whooping cough ☐YES ☐NO ☐DON’T KNOW
Measles, Mumps, Rubella (MMR) ☐YES ☐NO ☐DON’T KNOW
Pneumococcus ☐YES ☐NO ☐DON’T KNOW
Hepatitis A ☐YES ☐NO ☐DON’T KNOW
Hepatitis B ☐YES ☐NO ☐DON’T KNOW
Meningococcus ☐YES ☐NO ☐DON’T KNOW
Have you ever been hospitalized, significantly injured, had surgery, received a medical
treatment for longer than 2 weeks, suffer from unexplained symptoms, have been
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diagnosed with a disease (even if currently untreated), including psychiatric
conditions If YES, please explain in detail below:
_______________________________________________________________________
_______________________________________________________________________
Have you ever been told that your semen was abnormal YES☐ NO☐
Have you ever consulted an Urologist for infertility YES☐ NO☐
If so what is the Urologist’s name______________________________________
Have you ever suffered from sexual dysfunction YES☐ NO☐
Are there medical or genetic problems in your family If YES, please explain:
(A GENETIC PROBLEM IS DEFINED AS EITHER BIRTH OF A CHILD WITH BIRTH DEFECTS OR OCCURRENCE OF A
DISEASE IN MORE THAN ONE GENERATION)
Your father: ___________________________________________________________
Your mother: __________________________________________________________
Your siblings: __________________________________________________________
Others: _______________________________________________________________
Where is your family from in the world
Your father’s family: ________________________________________________
Your mother’s family: _______________________________________________
Do you consider yourself: ☐AFRICAN ☐ASIAN ☐CAUCASIAN ☐ Other: __________
Is your ethnicity: ☐American Indian ☐ Arab ☐Black ☐ Chinese ☐Hispanic
☐Indian (Asian) ☐Indonesian ☐Japanese ☐Jewish‐Ashkenazi
☐Jewish Sephardic ☐Pakistani ☐Philippine ☐White
☐Other: __________________________________________________
Tell us whether you
Smoke ☐YES ☐NO ☐QUIT (when ________) If YES, how many ____
Drink alcohol more than socially ☐YES ☐NO
Use illegal and/or prescription drugs ☐YES ☐NO
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_______________________________________________________________________
EXTRA COMMENTS:
_______________________________________________________________________
_______________________________________________________________________
HISTORY OF FERTILITY TREATMENTS
_______________________________________________________________________
What was your highest FSH ever measured _____ mIU/mL; When ___ / ___ / ___
What was your lowest AMH ever measured _____ ng/mL; When ___ / ___ / ___/
Do you have embryos or eggs frozen at another IVF center If YES, how many, and at
which center
___________________________________________________________
PRIOR FRESH IVF CYCLE HISTORY
_____________________________________________________________________
PLEASE LIST YOUR IVF CYCLE IN ORDER FROM 1 ‐ X, AND TELL US FOR EACH CYCLE THE APPROXIMATE DATE
STARTED, THE CENTER WHERE PERFORMED (IF POSSIBLE THE NAME OF TREATING PHYSICIAN), WHETHER THE
CYCLE REACHED EGG RETRIEVAL, HOW MANY EGGS WERE OBTAINED, HOW MANY FERTILIZED, WHETHER YOU
HAD AN EMBRYO TRANSFER, IF NOT, WHY NOT, HOW MANY EMBRYOS WERE TRANSFERRED, WHETHER AND
HOW MANY EMBRYOS WERE CRYOPRESERVED, AND WHAT YOU WERE TOLD ABOUT THE QUALITY OF
TRANSFERRED EMBRYOS. PLEASE DO NOT LIST HERE FROZEN‐TAHAWED IVF CYCLES.
1st_____________________________________________________________________________________________
2nd_____________________________________________________________________________________________
3rd_____________________________________________________________________________________________
4th_____________________________________________________________________________________________
5th_____________________________________________________________________________________________
6th_____________________________________________________________________________________________
7th_____________________________________________________________________________________________
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8th_____________________________________________________________________________________________
9th_____________________________________________________________________________________________
10th____________________________________________________________________________________________
Did any of your IVF cycles result in freezing of embryos If YES, which cycles (refer
to above cycle numbers), and list how many embryos were frozen in that cycle.
_______________________________________________________________________
_______________________________________________________________________
Did any of your IVF cycles involve culturing your embryos to blastocyst stage (day‐5)
If YES, which cycles (refer to above cycle numbers)
_______________________________________________________________________
Did any of your IVF cycles involve the use of preimplantation genetic diagnosis or
screening (PGD/PGS) If YES, which cycles (refer to above cycle numbers)
_______________________________________________________________________
Were any of your IVF cycles accompanied by complications, hospitalizations or other
unusual events If YES, please describe (and refer to above cycle numbers).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________________________________
ADDITIONAL COMMENTS
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Revised 4/8/13
Thank you for completing our questionnaire
The CHR
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